Monday, July 20, 2015

Forty years ago this month I moved to
Salt Lake City to continue my medical training. It was an exhilarating time in
health care. Major advances in medical technology seemed to occur every week. The
first clinical CAT (computerize axial tomography) scanners came online just as
I started my residencies. That advance was bracketed by the “Babybird”
respirator, infant incubators, MRIs, ultrasound, fiber optics, the Jarvik
artificial heart, lithium batteries, lasers, and many others. These new
technologies allowed clinicians to diagnose and treat conditions in ways
unimaginable ten years earlier; saving smaller and smaller babies and more
seriously ill children and adults than ever before.

During this time, our medical care
system was transformed. The new medical technologies fostered the development
and expansion of newborn intensive care units, tertiary care hospitals,
implantable pacemakers, medical transports, in vitro fertilization, and new micro
surgical techniques to name just a few. They accelerated the trend toward
specialization within the medical profession. We had great hopes and
expectations that a technology-enhanced clinical care system would lead to a
new level of health in our country.

Last week I returned to Salt Lake City
for the “State Health Departments’ Senior Deputies and Legislative Liaisons
Meeting” conducted by ASTHO (Association of State and Territorial Health
Officials). As I entered the city, I was struck by how much it had changed in
forty years. The Wasatch Mountains and the Great Salt Lake appeared the same
but, due greatly to the influence of the 2002 Winter Olympics, there were more
hotels, light rail, and one could now purchase alcohol in restaurants. There
was also a large homeless population – something non-existent in SLC forty
years ago. But the biggest change for me was the focus of the meeting
presentations and attendee conversations. They were not talking about the
promise and potential of our medical care system to improve health; they were
talking about its failures and limitations.

With forty years of hindsight it is
evident that, despite all its benefits, technology has not made us healthier
when compared with similar countries. In almost every health category,
including infant mortality, longevity, and health disparities, the U.S. has
fallen farther and farther behind other OECD (Organization for Economic
Co-operation and Development, i.e. industrialized) countries. And we have
achieved those poorer outcomes at a tremendous cost – both human and financial.
Until 1975, the percentage of the U.S. GDP (gross domestic product) spent on
health care paralleled that of other OECD countries. Since then, our
skyrocketing costs have significantly outpaced every other country.

Our supersized investments in medical
care have been mostly at the expense of investments in public health and human
services. The U.S. has the lowest percentage of GDP spent on human services
among the 28 OECD countries which spend more than 15% of their GDP on the
combination of medical care and human services. Yet, it is these investments in
public health and human services that are proving to be the most effective in
improving health. Moreover, the huge investments in high-tech medical care has
also lead to lost opportunity costs by stifling investments in education,
housing, transportation and other social determinants of health.

As I sat in the room listening to how we
need to create a new 21st century approach to protecting and
improving health, I thought back to the Mormon and Utah history I learned
during my three years in that unique state. On July 24, 1847, Brigham Young,
sick with Rocky Mountain Spotted Fever, saw in the distance the Salt Lake
Valley for the first time. Remembering an earlier vision about leading his
followers to a place where they could "make the desert blossom like a
rose," he proclaimed from the back of his wagon, "It is
enough. This is the right place. Drive on." The Latter Day Saints did
just that, they drove into the valley and helped make Young’s vision a reality.

The comments and questions from the
senior deputies and legislative liaisons from state health departments
throughout the country, made me aware that they were in one respect in the same
place, both literally and figuratively, as Brigham Young. They understood that
we’ve got enough data to know what creates health; that we’ve invested enough
in the health care path we’ve taken over the last 40 years; that we know what
needs to change to improve our health status; and that we don’t have to look
further for the time and place to start. The question they had was how to
instigate those changes? How do we invest in and implement a “health in all
policies” approach that addresses the physical, emotional, environmental, and
social determinants of health?

From what I heard last week in Salt Lake
City and what I’m observing throughout Minnesota and the rest of the country,
people are answering those questions. There is a growing consensus that,
relative to our investment in health care, “it is enough.” There is a
recognition that change needs to occur in the states because “this is the right
place.”

The place and time are right to make our
health deserts bloom so let’s “drive on” to create the policies, systems, programs,
and conditions in which all people can be healthy. It’s a great time for you
and me to be in public health and help shape the vision and the direction for
all 21st
century health pioneers.

Monday, July 6, 2015

Every year I have the opportunity to provide the
closing keynote address at the Minnesota Rural Health Conference. Not
wanting to be repetitious, I continually look for new perspectives on rural
health that might be helpful to conference attendees. As I began to
prepare this year’s remarks, I was made aware of a book of essays by Wendell
Berry, a poet, writer, and farmer from Henry County, Kentucky. Knowing
that his writings deal with healthy rural communities, sustainable agriculture,
appropriate use of technology, connection to place, and the interconnectedness
of life, I thought he might provide some inspiration.

I wasn’t disappointed.

In his essay “Health is Membership” Berry wrote that “…the
community in the fullest sense is the smallest unit of health…to speak of the
health of an isolated individual is a contradiction in terms.” That
statement both stunned and energized me. Public health is based on data
and measurement of health and this statement challenges how we currently think
about, define, and appraise health. Although we are learning how
individual health is profoundly affected by the environment in which people
live, work, and play, we struggle to find ways to measure and assess that
influence and appropriately improve it. The question is why?

You don’t have to go further than the guiding mantra
of today’s health care reform, the “Triple Aim,” to find the answer. The
“Triple Aim of Health Care” is: better care for individuals, lower per capita
costs, and better health for populations. The focus is entirely on
individuals. Even the population health aim looks at populations as the
summation of individually-focused data and interventions. There is no
direct or implied acknowledgement of the importance of community, which
reinforces the common narrative that health is due solely to high quality
health care and good personal choices.

The “Triple Aim” reinforces an industrial model of
health care that rewards efficiency and assumes bigger is better. It focuses
on the care of each individual and assumes that a person can be healthy
independent of outside factors. It strives for standardization and
evidence-based, best practices although only certain kinds of evidence are
acceptable. To best treat individuals with specific disease conditions,
health care has become increasingly specialized and technology dependent. This model, effective as it is in providing excellent care to some individuals,
discounts the importance of communities.

With that perspective, I had to conclude that the
“Triple Aim of Health Care” is potentially detrimental to health – particularly
rural health and health equity – and made that the premise of my speech. Knowing that my audience would be mostly health care providers, I made note to
emphasize that health care is not detrimental to health rather it’s the
health care systems put in place by the values represented by the “Triple
Aim.” Health care is an important and necessary contributor to health but
how it’s organized and funded is not necessarily best for the health of
communities and health equity. In other words, what’s good for our
health care system may not be good for communities or health equity.

The “Triple Aim” reinforces the notion that health is
the responsibility of the health care system. It crowns our health care
system as the benevolent dictator of health in our country. All of health
is viewed through a health care lens further reinforcing the narrative that
health is solely about health care. It allows the health care system to
dictate where health investments are made. That’s why public health and
social services are underfunded in the United States compared to other
countries and why other sectors that influence health are also under-resourced
due to the overly-resourced health care system.

Knowing that people would not want to leave the
conference on a negative note, I decided to offer an alternative triple aim for
consideration – the Triple Aim of Community Health and Health Equity:

Expand
our understanding about what creates health

Implement
a Health in All Policies approach with health equity as the goal

Strengthen
the capacity of communities to create their own healthy future

The value underlying these three components is
community connectedness – the social capital and social cohesion that’s
essential for individual and community health.

The Triple Aim of Community Health and Health Equity
is built on a community health model, not an efficiency model. It
recognizes that health is created in communities by the social, economic, and
environmental conditions in which people live, work, and play. It
acknowledges that every sector of the community (including health care) impacts
the community’s health. Most importantly, it recognizes the need for
communities to possess the power to address the conditions that impact their
health.

To build healthy communities, the health care system
should not be in charge of health nor should the public health system. The community needs to be in charge of health. Health care and public
health are crucial to creating healthy communities but are only two of multiple
partners who need to be at the program and policy tables where decisions are
made about how to invest in health for current community members and for
generations to come.

I made the above points in my speech and it was met
with polite applause. No one commented or challenged me or even asked a
question during the Q and A session so I was left wondering how the speech was
received. That was partially answered when three different people
approached me after the session and said, “We’ve been waiting for this speech
for twenty years. Our present system isn’t working for rural
communities. You explained why and you gave us a framework to change
that.”

As a farmer, Wendell Berry knows that the seeds he
plants determines the crop he harvests. The seed in his essay that
“health is membership” blossomed into my understanding that health and health
equity is community. Who knows what crop will spring from my
speech? If something grows, I hope it’s a crop of social connectedness
that shows us that community really is the smallest and most basic unit of
health.

Tuesday, May 26, 2015

In preparation for this summer’s “Pitch
the Commissioner (PTC)” tour around Minnesota, I managed to find some time
between rain showers this weekend to pitch a few horseshoes. Although the PTC
events are non-competitive, I wanted to practice in hopes of not embarrassing
myself in front of county commissioners, local public health officials, state
senators and representatives, health care providers, and community activists
who usually attend these functions. I discovered the 40 feet between stakes
seems to be getting longer each year.

As I pitched shoe after shoe, an old
proverb my mother frequently cited while I was growing up kept looping through
my mind:

For want of a nail the shoe was lost.

For want of a shoe the horse was lost.

For want of a horse the rider was lost.

For want of a rider the message was lost

For want of a message the battle was lost.

For want of a battle the kingdom was lost.

And all for the want of a horseshoe nail.

I was hoping this proverb might be a sign
that I would “nail” a few ringers but my errant throws quickly dispelled that
notion. Obviously, the message was not about horseshoes but prevention. The
more I pitched and the more I thought about the proverb the more I appreciated
the appropriateness of the horseshoe metaphor in public health.

Getting a ringer in horseshoes requires
the shoe to end up in the center of the pit. That means the shoe can’t be too
far left or right and it can’t be too long or too short. Given the presence of
those parameters, the shoe must also have the right orientation to encircle the
stake.

Similarly, to achieve good health, among
other things, there needs to be a balance between treatment and prevention and
between innovation and regulation. With those conditions in place, optimal
health also requires good choices by an individual.

The game of horseshoes is governed by
rules that assure the match is played fairly. To provide equitable opportunity
for everyone to compete, the rules allow a shorter pitching distance to
accommodate age, gender, and disability. While not in the rules, it’s assumed
that everyone who wants to play horseshoes has access to a horseshoe pitching
venue. In Minnesota that assumption is accurate because most pitches are in
parks or public spaces; free and open to everyone.

The rules and assumptions related to
health in our society are not as accommodating and equitable as in horseshoes. As
our 2014 Advancing Health Equity report notes, “…the opportunity to be healthy
is not equally available everywhere or for everyone in the state.” Whether it’s
housing, transportation, health care, education, food, or employment (the
determinants of health), the opportunities to be healthy are too often governed
by one’s race, income, education, sexual orientation, and geography. Unlike
horseshoes, few accommodations are made to allow everyone equal opportunity to
be health winners.

Having taken that metaphor as far as I
could, my mind went back to the proverb my mother taught me. I began to wonder
how each component in that verse linked with public health. It then struck me
that the horseshoe could represent the principle of social justice upon which
public health stands. And social justice is held in place by the nail of the
narrative that what creates health is investment in the public good (the
commons) and the social, economic, and environmental circumstances in which
people live. Sadly, this public health narrative has been displaced by the
currently dominant narrative which states that rugged individualism and market
forces are preeminent in determining health and prosperity; a narrative that
has brought us great disparities and inequities and limited the opportunities
for many to be optimally healthy.

With that in mind, each pitch of a
horseshoe brought forward a different line for the old proverb.

For want of a public health narrative
social justice was lost.

For want of social justice equity was lost.

For want of equity opportunity was lost.

For want of opportunity hope was lost.

For want of hope health was lost.

For want of health the community was lost.

All for the want of a public health
narrative.

Our job is to create and sustain (nail
down) a public health narrative about what really creates health and then pitch
that to as many people as possible. The “ringer” will be health equity and
optimal health for all.

Wednesday, March 18, 2015

Today
I was part of a press conference that focused on the health benefits of paid
leave – family leave and sick leave. The event was prompted by last
week’s release of our White Paper on Paid Leave and Health. As I was presenting our recent findings, I thought back to last year at
about this same time when we released our White Paper on Income and Health. That report helped add a health frame to the policy discussions
that ultimately led to an increase in Minnesota’s minimum wage. My hope
is that our recent report will also help bring a health perspective to another
important public health and public policy issue.

Given
that the press conference relating to a significant social policy was held on
St. Patrick’s Day, I decided to reprise a blog that I wrote at this time last
year. It’s as appropriate now as it was then. Just replace Minimum
Wage and Income and Health with Paid Leave.

On the south coast of County
Cork, Ireland is the sheltered seaport town of Cobh. The town is best known as
the final port of call of the RMS Titanic which sank on April 15, 1912 with a
death toll of 1,517. Another maritime disaster that is part of Cobh’s history
is the sinking of the RMS Lusitania on May 7, 1915. The Lusitania was torpedoed
by a German U-boat ten miles off the shore of Cobh with a loss of 1,198 lives.

Less well known is the fact
that for over a hundred years Cobh was the single most important emigration
center in Ireland. Between 1845 and 1851 over 1.5 million adults and children
emigrated from Ireland. Ultimately, over 6 million Irish people emigrated, with
over 2.5 million departing from Cobh.

I visited Cobh 6 years ago
and this quaint town resurfaced in my mind this weekend when I purchased some
corned beef in preparation for St. Patrick’s Day. I remembered that as I walked
along the docks of Cobh, the specter of those three traumatic events was
everywhere. Wherever I looked, whatever I read, and with whomever I talked,
these historical events which occurred 100 + years ago were still vivid in
people’s minds.

The more engrossed I became
in the stories of Cobh, the more I realized that the unifying lesson in all of
these events was the role of policy decisions in causing these tragedies.
Different individual or societal decisions could have prevented or
significantly reduced the loss of lives and the human trauma caused by these
events.

On the Titanic the number of
lifeboats was inadequate for the number of passengers. The ship had been
designed for more lifeboats but a decision was made to fit it with a lower
number that met the minimum requirements of an outdated law that based lifeboat
numbers on tonnage not on number of passengers. Plans were to add more only if
the law required them.

In early 1915 a policy
decision was made by the German military to do whatever was necessary to gain
control of the waters of the Atlantic Ocean. This decision led to the
torpedoing of the passenger ship Lusitania and the eventual US entry into World
War I – a war that killed or injured over 37 million people.

The policy decisions that led
to the starvation and mass emigration of the Irish were more subtle and
indirect but just as lethal as the iceberg and the torpedo that sunk the
Titanic and the Lusitania. Decades of state-sponsored discrimination promoted
laws that influenced all aspects of Irish life including the restriction of
education, the practice of religion, and the use of Gaelic by the Irish people.
It also fostered passage of the “penal laws” that affected land ownership and
led to total dependence on the potato for sustenance. These prejudicial
policies inevitably caused the 1.5 million deaths and mass emigration
precipitated by the potato famine that plagued Ireland for decades.

In each of these situations,
conscious policy decisions led to catastrophic results that negatively affected
the life and health of large numbers of people. Yet, none of these policy
decisions was related to health care. They were policies emanating from
consideration of business and political needs or the maintenance of a social
and economic order that favored those in power.

I relate this story about
Cobh not just for historical interest but because the impact of policies on
health continues to play out every day. The discussion around minimum wage, one
of the 2014 legislative session’s major policy issues, is a good example. The
debate has centered mostly on the business, economic, and political
ramifications of increasing the minimum wage. Yet, our recent report on “Income
and Health” points out the fact that minimum wage is a public health issue
– as income increases, health improves. Even though minimum wage is not being
heard in health committees, policy makers need to be aware of the individual
and community health implications of this policy decision.

Similarly, last month MDH
submitted a report to the legislature entitled “Advancing Health Equity in
Minnesota.” The report notes that “(w)hen groups face serious social,
economic and environmental disadvantages, such as structural racism and a
widespread lack of economic and educational opportunities, health inequities
are the result.” The report underscores the fact that health is determined
by much more than just health care. In fact, the majority of the health of
individuals and communities is influenced by the “non-health” sectors. When
health is not considered, policy decisions in these sectors often establish
barriers that inhibit equal opportunities for health for all. These policies
particularly affect“(t)hose with less money, and populations of color and
American Indians, (who) consistently have less opportunity for health and
experience worse health outcomes.”

Certainly, “health care
policies” need to be part of the policy milieu that influences health. However,
the example of Cobh demonstrates that business, occupational, educational,
transportation, economic, and social policies can have an even larger impact on
the survival and health of individuals and communities.

As the state’s lead public
health agency, MDH has a responsibility to help create the conditions in which
all Minnesotans can be healthy and that responsibility goes far beyond just
dealing with issues in the clinical care and public health arenas. To be true
to the vision of advancing health and health equity, MDH and all public health
professionals need to be actively involved in assessing and monitoring policies
at the local, state, and national levels that could have a health impact and
advocating for decisions that will ultimately benefit the health of all
Minnesotans and every community in our state.

The history of Cobh reminds
us that policy decisions are important to the health of the public. There is
health in all policies.

Tuesday, March 3, 2015

Every March I go to Washington D. C. to meet with federal
agency heads and visit with the Minnesota congressional delegation. Today, my arrival in D.C. coincided with the arrival of Israeli Prime Minister Benjamin Netanyahu. Because of that
coincidence, getting to my hotel took longer than usual as the cab had to
navigate around police barricades and groups of protesters. That extra
time in the taxi allowed me to ponder the polarization that’s so prevalent in
our society. On almost every issue – from the Affordable Care Act through
immigration reform to funding of Homeland Security and research on zoonotic
diseases – the protagonists and antagonists appear to be acting like each other
has an infectious disease that requires as much separation as possible. Sparked by the Prime Minister’s scheduled appearance before a joint session of
Congress tomorrow, that polarization was blatantly evident throughout our
nation’s capital today.

Although the
rhetoric is less intense and the issues not as prominent, Minnesota certainly
hasn’t escaped from partisan polarization.

With that thought in mind as I watched the green light
turn red for the third time without the cab moving, I remembered that today was
the birthday of Theodor Seuss Geisel. Not surprisingly, I immediately
thought of one of my favorite Dr. Seuss books, The Butter Battle Book, which
begins:

On the last day of summer, ten hours before Fall…

my grandfather took me out to the wall.

For a while he stood silent. Then finally he said,

with a very sad shake of his very old head,

“As you know, on this side of the Wall we are Yooks.

On the far other side of this Wall live the Zooks.”

Then my grandfather said, “It’s high time that you
knew

of the terribly horrible thing that Zooks do.

In every Zook house and in every Zook town

every Zook eats his bread with the butter side down!”

“But we Yooks, as you know, when we breakfast or sup,

spread our bread,” Grandpa said, “with the butter side
up.

That’s the right, honest way!” Grandpa gritted his
teeth.

“So you can’t trust a Zook who spreads bread
underneath!

While the nuclear arms race was the basis of that story,
Dr. Seuss could just as easily have used any of today’s controversies as his
inspiration because, in Washington and throughout the country, people are using
their Boom Blitzers, Blue Gooers, and Big-Boy Boomeroos to throw invectives at
those who think differently than they do about myriad issues. And what
has it gotten us - a stalemate on most important issues and mutually assured
destruction of anyone who tries to collaborate or compromise. Health
policy seems to be ground zero for many of these debates.

Is it possible to get away from this brinksmanship and
find a way to break down walls and collaboratively develop rational health
policies? Given the entrenched positions in Washington, it’s probably not
possible there – at least not now. Perhaps it can be done at the state
level; especially in a state like Minnesota which has a history of coming
together for the common good. But who could help make that happen?

I contend that it is our role as public health workers
(some of whom are Yooks and some Zooks) to help make that happen.
Building on the fact that most people value health on both the individual and
community level, we have the opportunity and responsibility to foster a
conversation about what creates health. We need to broaden that
conversation beyond just the policy makers on one side of the aisle or the
other and actively engage community members because everyone has a stake and
responsibility in creating the conditions for health.

The health of the public should not be a partisan issue –
it is an issue that benefits everyone and everyone’s input is needed. Our
role in public health is to create the opportunity for all voices and
perspectives on health issues to be heard and foster respectful and
non-judgmental debate - essentials for the development of rational and
effective approaches to creating health for everyone. Now is the time to
create that opportunity because, as was stated in Horton Hears a Who, another
of my favorite Dr. Seuss stories:

"This", cried the Mayor, "is your
town's darkest hour!
The time for all Whos who have blood that is red
To come to the aid of their country!", he said.
"We've GOT to make noises in greater amounts!
So, open your mouth, lad! For every voice counts!"

Monday, January 26, 2015

(I was invited to speak today at a church service and attend a
post-service forum about what they could do to make health care more accessible
and affordable. I was unable to stay for the forum so I’m not sure what they
decided to do. However, I thought you might be interested in some of my
comments to the congregation as preparation for their discussion.)

When I was a junior in high school
and was debating what career path I should take, I came across the book The
Other America by Michael Harrington. The book started with this passage:

“There is a familiar
America. It is celebrated in speeches and advertised on television and in
magazines. It has the highest mass standard of living the world has ever known…
but, there is another America. In it dwells somewhere between 40,000,000 and
50,000,000 citizens of this land. They are poor. … tens of millions of
Americans are, at this very moment, maimed in body and spirit, existing at
levels beneath those necessary for human decency. … They are without adequate
housing and education and medical care.”

It was that book and the picture that it
painted about the disparities and inequities that existed in our country that
prompted me to choose a career in medicine; thinking that being a physician and
working in underserved areas would be an effective way to address those
disparities.

Sadly, after more than 40 years as a physician,
what was written in 1962 is as accurate and as relevant today as it was then. “There
are millions of Americans maimed in body and spirit existing at levels beneath
those necessary for human decency, without adequate housing, education, and
medical care.”

The persistence of the health problems in our
country is certainly not because we haven’t worked on the issues or spent money
on them. Despite talking about health reform every year for the last four decades
and spending more money on health care than any other country in the world, we
are far from the healthiest population on the planet.

Fortunately, I was not the only one affected by
Michael Harrington’s book The Other America. It was read by John F. Kennedy
and it formed the basis of his social and economic agenda that ultimately led to
the Johnson era Great Society programs and the War on Poverty.

I mention that today because it’s exactly 50
years ago this month that the 89th congress was convened, arguably
the most productive congress in history. It was a congress that addressed the
inequities in our society in ways not seen since then. This is the congress
that passed, among other things:

Medicare and Medicaid

The Voting Rights Act (a year after the
Civil Rights Act)

Job Corps

VISTA

Peace Corps

School lunch program

Food stamps

Head Start

Neighborhood health centers

Older Americans Act

Elementary & Higher Education Act

Housing & Urban Development Act

Vocational Rehabilitation Act

The Freedom of Information Act

Cigarette labeling and advertising act

Public Works and Economic Development Act

National Foundation on the Arts and the
Humanities Act

Immigration and Nationality Act

Motor Vehicle Air Pollution Control Act

Highway Beautification Act

National Traffic and Motor Vehicle Safety
Act

National Historic Preservation Act

National Wildlife Refuge System Act

Department of Transportation Act

many more

People argue about whether or not the Great
Society programs and the War on Poverty worked. From my public health
perspective, they were a resounding success. Poverty rates declined, especially
for the elderly. We had a more balanced investment in health and social
services and what we spent on health care remained in-line with what other
developed countries were spending. And our overall health status improved and
health disparities were reduced.

The activities that emanated from this national
effort reflected what I discovered in my first three months of medical practice –
that medical care alone will not make us healthy. I learned quickly that even
if I spent every day of my medical career treating dozens of people with
diseases, injuries, and disabilities, the overall health of the community would
not improve. The unhealthy physical, social, and economic environment in which
my patients lived overwhelmed whatever care I could provide. I learned that
access to high quality medical care is necessary, but not sufficient, to create
a healthy society.

While understanding that medical care is of
crucial importance, the policy makers in the 89th congress
recognized that it is the policies, systems, and the socioeconomic and
physical environments that play the biggest role in determining health. That’s
why they not only invested in medical care through Medicare and Medicaid, but
also invested in economic development, education, housing, transportation,
environmental protection, and a whole lot more. They also empowered communities
to become engaged in the decision-making process that developed and implemented
programs and initiatives. In addition, they understood that health is not
solely under the purview of the health care sector – that every sector is
necessary to create a healthy society. In the public health parlance of today,
they took a health in all policies approach. They invested in the public good. They
invested in the commons. They invested in communities.

We need to learn from that experience because
our research now demonstrates the wisdom of that approach in that
socioeconomic conditions have been shown to account for more than 50% of our health
while medical care contributes about 10%.

We also now know that it’s the disparities in
education, income, wealth, housing, and access to a variety of services that
lead to health disparities and that those disparities affect the overall health
of the community – even those at the top of the socioeconomic ladder. We also
recognize that these disparities don’t happen by accident. They are the result
of policies that systematically disadvantage some groups, particularly low income
populations and people of color and American Indians. That’s why it’s not
surprising that the Great Society efforts to improve the health of all
Americans were linked with the Civil Rights movement. A socially just society
leads to better health for everyone. That’s why the Minnesota Department of
Health has made advancing health equity the central focus of our efforts to
create a healthier Minnesota.

Unfortunately, the Great Society programs were
affected by the Vietnam War which stressed our budget and undermined our trust
in government. In the early 1980s a variety of factors led to the dismantling
or reduction in support for some of those Great Society programs.

That was also the time when the conversation
about what creates health was being systematically recrafted. What emerged was
the narrative that health is determined by personal choices and access to
medical care. The narrative was that if people simply had health insurance that
provided access to high quality health care and they made good choices about
diet, exercise, and drug use, they would be healthy.

Looking back, it was at that point that we
began to disinvest in the public good and abandoned our community-oriented
approach to health and increased our investment in medical care. It was also
when our health status (compared to other countries) began to decline, when
disparities began to increase, when homelessness and hunger began to reappear,
and when our health care costs began to rise astronomically.

That narrative about the primacy of medical
care and individual responsibility remains dominant today. It’s that narrative
that drives our health policy and it distracts us from what really creates
health.

The truth is that health care accounts for only
about 10% of our health and personal behaviors account for less than 30% and
many of those are often outside the control of the individual. It’s hard to
choose healthy food when you are poor and live in a food desert. It’s difficult
to be physically active when your neighborhood is unsafe or you are working three jobs just to survive.

Well over 50% of our health is determined by
the physical and socioeconomic environment in which we live, learn, work,
play, and pray. Despite that, over 95% of our rapidly increasing health expenditures
go toward clinical care which obviates the investments in the social and
economic conditions necessary to create health for everyone. Without these
investments in the community good, which will help prevent the development of
disease and disability, the costs of health care will continue to rise.

While it’s important to work for universal
access to high quality, culturally appropriate health care, the health of our
society cannot be improved solely by those efforts. Certainly, having universal
access to a single-payer system would help. But, in fact, our myopic focus
solely on health care, health insurance, and medical financing mechanisms,
actually interferes with what needs to be done to effectively improve our
health. It limits the scope of the needed discussions around health and it
limits the discussion to experts in the field of health care. What really is
required is the active involvement of all people from all sectors of our
society who recognize and understand the broader determinants of health and are
willing to work to create a society that is more socially responsible and
socially just.

That’s where you come in. As individuals and as
a community, you can help change the narrative about what creates health. You
can attest to the fact that it’s the policies and systems that create the
conditions that support or undermine health. And it’s not just the official
health policies that are crucial but the education, housing, transportation,
environmental, and economic policies. You can make the case that many in our
society don’t have the opportunity to make healthy choices because they are
limited by their income, their education, their neighborhood, or their
mobility. You can work toward policies that assure a livable wage, paid parental
and sick leave, safe and stable housing, effective transportation,
incarceration justice, educational achievement, and much more. You can bring an
equity lens, a social justice lens, to those conversations recognizing that as
Paul Wellstone said, “We all do better, when we all do better.” And you
can hold policy makers and public officials like me accountable for the
decisions that affect our communities.

Public health is defined as what we, as a
society, do collectively to assure the conditions in which all people can be
healthy. That definition doesn't say anything about doctors or nurses or
hospitals or clinics. It doesn't even mention health departments. It includes
all of us as a society. All of us are responsible for creating the conditions
in which people can be healthy. It’s our job, not someone else’s. All of us are
part of the collective effort necessary to build a socially just society.

What better place to start that work than here?
What better time than now?

Tuesday, January 13, 2015

Like
every other commissioner in attendance, I listened closely to Governor Dayton’s
2015 Inaugural Address for any reference to issues related to my agency.
Although I didn’t hear specific references to health or the Minnesota
Department of Health (MDH), I was pleased with what I heard – a speech
constructed around principles, goals, and initiatives that should gratify
anyone concerned about the long-term health of the public.

The
speech began with an emphasis on economic security and education – two of the
greatest determinants of health – and concluded with a call for “community”
recognizing that “what binds us together is much more important than what
pulls us apart. What helps one region usually benefits our entire state.”
It was the Governor’s take on the Institute of Medicine definition of public
health as all of us working “collectively to assure the conditions in which
people can be healthy.”

In
between, the Governor underscored issues that are core to public health:
inequities (“inequities in wealth and income are at record highs”) and
the need to strike a balance between spending on current needs and investing in
the future welfare of our state (“Spending is for now…Investing is for the
future…to produce future benefits and rewards. Wise financial management
requires understanding this difference and striking a proper balance between
them.”) That echoed what public health workers have been saying about
balancing investments in treatment and prevention, medical care and public
health. He tied all these themes together by recommending “that our
top priority be to invest in a better future – by investing it in excellent
education…and making that educational excellence available to everyone.”

The
Governor emphasized education because“…an excellent education unlocks the
door to unprecedented opportunities. Our future success – the health of
our families, the vitality of our communities, and the prosperity of our state
– will depend upon our making those excellent educations available to all
Minnesotans…education is the key to our survival.” That
certainly underscored the MDH vision for advancing health equity – that
everyone have equal opportunities to be healthy.

In
concluding his speech with a call for community, Governor Dayton urged that we
should cast “Minnesota modesty aside – we should be proud because we so
often are the best…(having) earned (that) through smart minds, good ideas, and
hard work; through all of us pulling together and making our state – despite
lacking the advantages of ocean beaches, or Rocky Mountains, or fossil fuel
riches – into a place (that is) unique and extraordinary. A state upon
which we proudly emblazon our motto: ‘L’Etoile du Nord,’ ‘The Star of the
North,’ and bequeath it even brighter to future generations.”

As
I stood with the rest of the crowd applauding, I thought “that was a great
public health speech;” a speech that should challenge all of us for the next
four years in creating a legacy of health and equity for our children,
grandchildren, and great grandchildren. Perhaps we even have the
opportunity to create another “Minnesota Miracle” – one appropriate for the 21st
century.